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The nurse is caring for a client with acute kidney injury (AKI) secondary to gentamicin therapy. The client's serum blood potassium is elevated. Which finding requires immediate action by the nurse?
- A. Anuria for the last 12 hours.
- B. Tachycardia and hypotension.
- C. Decreased urine output.
- D. Elevated blood urea nitrogen (BUN) levels.
Correct Answer: A
Rationale: The correct answer is A. Anuria for the last 12 hours. Anuria, the absence of urine output, indicates complete kidney failure and is a medical emergency that requires immediate attention. In acute kidney injury (AKI), the kidneys are unable to filter waste from the blood effectively, leading to a buildup of toxins and electrolyte imbalances like elevated blood potassium levels. Tachycardia and hypotension (choice B) can be seen in AKI but do not reflect the urgency of addressing anuria. Decreased urine output (choice C) is concerning but not as critical as the absence of urine production. Elevated blood urea nitrogen (BUN) levels (choice D) are indicative of kidney dysfunction but do not demand immediate action as anuria does.
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A client with end-stage renal disease (ESRD) is scheduled for hemodialysis. Which laboratory value should the nurse report to the healthcare provider immediately?
- A. Serum potassium of 5.5 mEq/L
- B. Serum calcium of 8 mg/dL
- C. Serum creatinine of 2.0 mg/dL
- D. White blood cell count of 10,000/mm³
Correct Answer: A
Rationale: A serum potassium level of 5.5 mEq/L is concerning in a client with ESRD scheduled for hemodialysis as it indicates hyperkalemia, requiring immediate intervention. Hyperkalemia can lead to serious cardiac arrhythmias, especially during hemodialysis. Serum calcium, serum creatinine, and white blood cell count, while important, do not pose immediate life-threatening risks like hyperkalemia.
A client with a history of chronic kidney disease (CKD) is admitted with hyperkalemia. Which clinical finding is most concerning?
- A. Peaked T waves on the ECG
- B. Bradycardia
- C. Muscle weakness
- D. Decreased deep tendon reflexes
Correct Answer: A
Rationale: Peaked T waves on the ECG are the most concerning finding in a client with hyperkalemia. Hyperkalemia can lead to serious cardiac complications, including arrhythmias and cardiac arrest. Peaked T waves are a classic ECG finding associated with hyperkalemia and indicate the need for immediate intervention. Bradycardia, muscle weakness, and decreased deep tendon reflexes can also be seen in hyperkalemia, but the presence of peaked T waves signifies a higher risk of cardiac events, making it the most concerning finding in this scenario.
The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine, and the UAP is placing soft pillows along the side rails. What action should the nurse take?
- A. Ensure that the UAP has positioned the pillows effectively to protect the client.
- B. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.
- C. Assume responsibility for placing the pillows while the UAP completes another task.
- D. Ask the UAP to use some of the pillows to prop the client in a side-lying position.
Correct Answer: B
Rationale: The nurse should instruct the UAP to pad the side rails with soft blankets instead of pillows. Placing pillows along the side rails could lead to suffocation during a seizure and would need to be removed promptly. Instructing the UAP to use soft blankets is safer as they can help prevent injury without posing a risk of suffocation. Ensuring effective placement of the pillows (Choice A) is not appropriate as pillows should not be used in this situation. Assuming responsibility for placing the pillows (Choice C) or propping the client in a side-lying position with pillows (Choice D) are both unsafe actions and could potentially harm the client.
A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which clinical finding is most concerning?
- A. Serum glucose of 500 mg/dL
- B. Serum glucose of 600 mg/dL
- C. Serum potassium of 5.5 mEq/L
- D. Serum bicarbonate of 18 mEq/L
Correct Answer: D
Rationale: A serum bicarbonate level of 18 mEq/L is most concerning in a client with DKA as it indicates metabolic acidosis, requiring immediate intervention. In DKA, the body produces excess ketones, leading to metabolic acidosis. A low serum bicarbonate level is a key indicator of this acid-base imbalance. Elevated serum glucose levels are expected in DKA but are managed through insulin therapy. Serum potassium levels can fluctuate in DKA due to insulin deficiency, but a value of 5.5 mEq/L is not as immediately concerning as metabolic acidosis. Therefore, the most critical finding in this scenario is the low serum bicarbonate level.
A preschooler with constipation needs to increase fiber intake. Which snack suggestion should the nurse provide?
- A. Oatmeal cookies
- B. Cheese sticks
- C. Yogurt
- D. Apple slices
Correct Answer: A
Rationale: Oatmeal cookies are the best snack suggestion for a preschooler with constipation needing to increase fiber intake. Oatmeal is high in fiber, which helps relieve constipation. Cheese sticks, yogurt, and apple slices are not as high in fiber content as oatmeal and may not be as effective in addressing the constipation issue in this scenario.